Provider Demographics
NPI:1740615558
Name:KANE, MARK BRIEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:BRIEN
Last Name:KANE
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4227
Mailing Address - Country:US
Mailing Address - Phone:970-384-7033
Mailing Address - Fax:970-384-8174
Practice Address - Street 1:5176 HILL RD E
Practice Address - Street 2:SUTTER-LAKESIDE HOSPITAL, ATTN: EMERGENCY DEPARTMENT
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-262-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA23128363AM0700X
COPA.0005001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical